Ob-Gyn Coding Alert

Question: I am attempting to understand the issue of laparoscopic pelvic lymphadenectomies done in conjunction with other laparoscopic surgery. In the CPT^® book, there are two codes for laparoscopic pelvic lymphadenectomies: 38571 and 38572. I have been unable to find a list of lymph nodes (or groups of lymph nodes) that constitute a laparoscopic “bilateral total pelvic lymphadenectomy.” I have several questions since I haven’t been able to find this information:

• Do you know which group of lymph nodes would constitute a “total pelvic lymphadenectomy”?
• Do you know which lymph nodes are excised using a “common template,” and would it constitute a total pelvic lymphadenectomy?
• If the surgeon removes fewer lymph nodes than a total (partial pelvic lymphadenectomy), would you recommend the unlisted code (38579) since the provider is doing more than a lymph node biopsy (38570)?​

Connecticut Subscriber

Answer: First, let’s look at the descriptors for the two procedure codes you mention:

• 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy)
• 38572 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple).

The external iliac, internal iliac, and obturator (hypogastric) nodes are all part of a pelvic lymphadenectomy. And while the code’s description does not indicate which nodes are to be removed, the clinical vignette used to add this code to CPT^® does: According to the description of the procedure “The peritoneum is incised overlying the external iliac vessels, and lymph node dissection is performed. Boundaries of the dissection are the genitofemoral nerve laterally, the circumflex iliac vein or Cloquet’s node inferiorly, the bladder medially, the bifurcation of the common iliac artery superiorly, and the floor of the obturator fossa deep. All lymph-node-bearing tissue in this area is removed to include external iliac, internal iliac, and obturator (hypogastric) lymph node.” While the number of nodes removed is not specified, the intention is that all nodes within the area are to be removed bilaterally in order to use this code.

Caveat: Remember if the surgeon performs only a unilateral resection, append modifier 52 (Reduced services) to 38571 and document the ob-gyn’s work.

If the ob-gyn removes nodes located higher than the pelvic nodes (e.g., those at and above the aortic and vena cava bifurcation), submit 38572 for an extended node resection. Finally, clinically there is no discrete delineation between the groups of nodes because of the many anatomical lymph nodes variation and therefore, the lack of coding.

It would be appropriate to use the unlisted code for a limited laparoscopic lymphadenectomy.